Beginnings Guides Blog

Raising a Reader

05/01/2012 19:32:00

My work with Parents as Teachers (PAT) in recent years has

shown me that with encouragement and guidance parents,

even those with low skills, enjoy reading to their children,

and so jump starting their emerging literacy. PAT parent

educators promote reading to infants and toddlers to help

them become school ready. Here’s a checklist from the

Beginnings Parent’s Guide for child aged 16-18 months.

Use it in a reflective conversation with a parent about

supporting child development. When a parent checks most

of the boxes, she is giving her toddler a great gift, a taste

for learning. Praise her for being a good teacher.

It’s never too early or too late to start reading to a child

and encouraging them to “read” for fun. This is my

granddaughter Samantha at about 8 months . She spent

her first year in my office as a “Research Assistant”. Her

favorite book was the supplies catalog.

Are you Raising a Reader?

[ ] I read to my child in a special cozy place that he likes.

[ ] I show him pictures and ask questions that make him

think, like Where is the cat? Where is our cat?

[ ] I change my voice to show feelings. I make animal noises and

use a different voice for each actor in the story.

[ ] Baby enjoys the books we read. I let him choose. He likes to

read the same one over and over.

[ ] I watch how my child responds to the story and follow his lead.

He sets the pace and turns the pages.

[ ] I tie ideas in the story to things he knows and sees.

“There is a red ball just like yours.”

Are parents in your state reading to their little ones?

You can see what proportion of parents in your state read to their

children daily in Zero To Three’s Baby Facts. In my state, Washington,

its 61%.

Where does your state rank for child well-being?

05/01/2012 19:29:00

Where does your state rank for child well-being?

What percent of children on Medicaid in your state have

a medical home? What percent of mothers get early prenatal

care? What are the big challenges for maternal child health?

Find out all this and more at State Baby Facts from the

Zero To Three Policy Center.

I checked out Texas

I’m preparing to implement a health literacy promotion

program in Texas. So I clicked the Lone Start State on

the State Baby Facts map. I got a four-page report with

five pages of references. Here are some of the highlights

I found useful:

Texas ranks 35th among the states for child well-being,

just behind Missouri.

53% of infants and toddlers live in low-income families;

compared to 46% nationwide (in the world’s wealthiest country!)

About 20% of these families pay over half of their income in rent.

59% of Texan babies’ mothers got early prenatal care.

(The Healthy People 2020 objective is 90%)

56% of births in Texas are financed by Medicaid.

56% of children on Medicaid have a medical home.

13.3% of Texan babies are born preterm. 8.4% are low-birth-weight.

Families in home visitation programs: 3,285 in 2009

If you are advocating for families, this is a great place to start.

Another reason I’m proud to be a ZTT Graduate Fellow.

Building the Bike While Riding It:

05/01/2012 19:26:00

Action research identifies best practices for promoting

maternal health literacy

Following is a brief summary of findings from our program

of action research* with home visitation programs that have

been trained to use Beginnings Guides and the Life Skills

Progression to support reflective practice and promote

maternal health literacy.

Home Visiting (MECHV) is an effective channel to promote

maternal health literacy,

Overall mothers (N=2572 including 23 men and a few grandparents)

who participated in enhanced home visitation for 12-18 months

achieved significant improvement in their use of information and

services for health.

Learn more

Promoting Maternal Health Literacy reduces disparities

Additional findings suggest the intervention reduced disparities

related to literacy and age:

• Lower skilled readers made greater gains than their more

skilled counterparts.

• Teen mothers started at a major disadvantage but made

impressive gains in the first six months of service to nearly

catch up with their more experienced counterparts.

Depression and Maternal Health Literacy closely linked

• Both depressed and not-depressed mothers improved their

management of personal and child health and healthcare.

Depressed mothers made greater gains than not-depressed

mothers, again reducing disparities.

Learn more

Depression does not interfere with health literacy promotion efforts

• Depression improved slightly but significantly over the service

period. Home visitors were successful in supporting mothers to

overcome multiple barriers to obtain depression treatment,

demonstrating increased understanding and utilization of health

services -- that’s health literacy. Major improvements in health

literacy occurred even when changes in depression were minor,

suggesting the effect on health literacy is separate from the effect

on depression. Read article in Maternal and Child Health Journal

(full text free online).

Maternal Health Literacy may predict child developmental outcomes

Preliminary findings from our current study on the same database as

the above studies suggests maternal health literacy is closely related

to child development, so that efforts to promote health literacy also

promote child development. Stay tuned.

Learn more

Is it feasible and effective to integrate health literacy promotion

into Medical Home Outreach?

This question is being addressed over the next two years with

Anthem/WellPoint as it pilots the intervention in 12 state Medicaid

managed care organizations. WI is up. TX is next.

Stay tuned.

Integrating health literacy promotion into Parents As Teachers

curriculum is feasible and effective

That is the preliminary finding from the Parents As Teachers Health

Literacy Demonstration Project that winds up this summer. The

participating Parent Educators and other stakeholders will review

and interpret the results at a Reflection Conference May 11.

Stay tuned.

Learn more

* Action research, sometimes called “practitioner research”,

is a reflective process in which practitioners undertake research

to improve their own practice by learning from experience.

The process identifies ineffective practices to drop; promising

practices to hone and finally best practices to disseminate.

See Forest, M.E. & McNiff, J. (2007). Learning and teaching in action.

Health Information and Libraries Journal, 24, 222-226.

The Gift of a Reflective Question

04/16/2012 08:55:00

A reflective question is one that requires the mother to think about facts and feelings, link to her knowledge and experience, and formulate a purposeful response. For health action planning, reflective questions help the mother clarify what she wants for herself and her child, clarify what is currently supporting or in the way of her desired outcome, and clarify the next step. Hint: a Yes or No question is not reflective.

Home Visitor Asks

Demonstrates it matters what a mother knows
Builds mother's confidence
Creates a teachable moment
Suggests a way to think about a current problem
Presents the mother opportunity to recognize & apply her knowledge & experience-to use her power
Presents the mother opportunity to notice gaps in her knowledge & to seek info
Teaches responsively-leaves the power with the mother by supplying info only in response to her request
She empowers the mother

Mother Reflects

Feels respected, knowledgeable, self-confident in caring for herself & baby

Taps into her experience, uses her knowledge
Evaluates her experience, values, knowledge, feelings
Applies and so learns from her experience
Recognizes her need to know & need for info
Asks for info-takes charge of her learning
Increases knowledge
Develops her life skills-problem solving, resource utilization, info seeking
Changes behavior
Improves baby care, interaction, teaching
She is empowered

Baby Benefits

Has his/her needs met
Establishes trust in the mother
Achieves secure attachment
Enjoys improved health & well being
Learns appropriate behaviors
Reduced risk of abuse & neglect
Innate curiosity is supported
Improved school readiness

Breastfeeding Recommendations & Maternal Health Literacy

04/03/2012 17:06:00

Reports have been circulating on the Internet: researchers

find that the recommendation to exclusively breastfeed babies

for six months is just too hard for modern women and is making

mothers feel bad. The study author suggests the advice is fine

for the developing world, but should be changed to “breastfeed

as long as you can and introduce solids as close to six months as

possible”.

There are several health literacy lessons to be learned from this

questionable reporting on questionable research.

The evidence is exceptionally clear and strong

First, we should note that the recommendation to feed infants

only breast milk for at least six months is not just a suggestion

from some guy in a diner. It is the evidence-based consensus from

the U.S. Centers for Disease Control, American Academy of

Pediatrics, the World Health Organization, and virtually all health

agencies on the planet. This level of consensus is rare and requires

an extremely strong evidence base.

Is the recommendation unhelpful for mothers?

The evidence exists for a long list of health benefits to mother

and child that last a lifetime and save billions in healthcare costs.

The study’s author says the recommendation is “idealistic” and
“unhelpful” as an individual goal and calls for balance between

these “theoretical” longterm benefits and immediate family well

being.Fair enough. But that can be done at the individual level

without undoing worldwide policy making and without concluding

that women are incapable of (or just too busy) for this womanly skill.

The perfect food is free

The big problem for breastfeeding is this: it’s free. This study

feeds a broadly-held perception that breastfeeding is for poor

people in backward countries that cannot afford or reliably use

formula.

With this twisted thinking we are willing to disregard all the

science behind the global breastfeeding recommendation in

favor of the belief that in 30 years scientists have made a better

formula than what Mother Nature developed over millennia.

Health Literacy Lessons

According to the World Health Organization, Maternal Health

Literacy means the cognitive and social skills which determine

the motivation and ability of mothers to gain access to, understand,

and use information in ways that promote and maintain their

health and that of their children.

Part of health literacy for mothers, health promoters and

clinicians alike, is reading critically, asking where is this information

coming from and how reliable is it? What does it mean to me in

my situation? How can Iuse it for health?

Read it for yourself. The study is published in BMJ Open- that’s

British Medical Journal Open, an open access journal.

BMJ ought to be a reliable source. But here’s the detail that matters

(it’s in the abstract): 541 pregnant women in Scotland were invited

to participate in monthly interviews; 72 volunteered to participate.

Of these, 36 were interviewed along with some of their partners and

relatives.

This is not a representative sample. People who volunteer to

participate in surveys typically feel very strongly one way or the

other. We need to ask, how are these 36 women different from

the 505 who declined? Further, the sample is too small to draw

any conclusions beyond the individuals involved.

Telling them what to do does not work

Breastfeeding advocates, health educators, parent educators,

home visitors, clinicians can learn an important lesson re: promoting

maternal health literacy from this article. When education

is perceived as “unrealistic, overly technical and rule based”, it is

not going to motivate anyone to take action for health. But you

already knew that...The problem here is not the breastfeeding

policy; it’ s the delivery of information.

Stay tuned for a model reflective conversation to promote

breastfeeding.

To balance the oft quoted Scottish mothers who were not well served by

their lactation consultants and who struggled with breastfeeding, see our

Facebook Poll for comments from our volunteer sample of mothers who

work in women’s health. We asked: Do you think recommending

breastfeeding for a minimum of 6 months is unrealistic or unattainable?

No one said Yes.

2nd and 3rd Hand Smoke Harms Child Health throughout Life

03/22/2012 15:41:00

Betty, a parent educator presented a challenging case in

reflective supervision. She reported that the 19-year old

mother and her seven month-old daughter live with her

mother. And Grandma smokes like a chimney. Mom smokes,

too. She’s begun making efforts to smoke outside. But

Grandma says to Mom, “I smoked all through my pregnancy

and your childhood; you didn’t die, and neither will this

child”. She bristles at any request to stop smoking or take

steps to protect the baby.

I have a lot of respect for grandmothers and their wisdom

(I am one!). But this time, this grandmother is just plain

wrong. Her smoking probably will not kill the child this

year, and hasn’t killed the mother yet, but it might kill

them both before their time.

Second-hand smoke is as harmful as first hand smoke,

and more so for an infant with small size and still-developing

lungs. Exposure to second hand smoke has been linked to

increased risk of SIDS, ear infections, and respiratory disease in

children. Annually, 150,000 to 300,000 cases of bronchitis

or pneumonia in children under 18 months of age are attributed

to second hand smoke. And new research reported by the journal

Respirology this week shows that a child’s reduced lung function

from exposure to second-hand smoke nearly doubles the risk of

lung disease in adulthood.

Mom smoking outside does begin to reduce harm to the baby by

reducing the second hand smoke in the air that Baby breathes.

Betty, the home visitor rightly praises this effort and continues

to encourage Mom to take the next step. Mom is in a bind because

she needs a safe place to live. And, for now, living with her

mother is her best option. She has set a goal to get a job so she

can get her own place. She is taking courses for a college degree.

It’s a long path to her goal. Meanwhile, Betty reports, she takes

the baby to the doctor “all the time” for recurring colds and ear

infections.

Third-hand smoke is as harmful as first hand smoke, too.

What makes Grandma’s house hazardous to Baby’s health, in

addition to smoke in the air from her current cigarette, is the

accumulation of smoke in the furniture, curtains, carpet, bedding,

dust; in her hair and clothes, and in her car. This is third-hand

smoke. It toxins remain toxic. Baby has her face in it all the time.

Information on third-hand smoke will be added to the upcoming

4th Edition of the Beginnings Parents Guide.

Rating Moms and Grandma’s Health Literacy

Betty has made certain that both Mom and Grandma have plenty

of information about smoking and resources to support quitting.

Both understand the information. Grandma rejects it outright.

She warrants a low score of 1 (dysfunctional) on the “Use of

Information” item in the Life Skills Progression Maternal Health

Literacy Scale. She has low health literacy, not because she can’t

read, but because she does not use information and resources for

health.

Mom’s health literacy is increasing. With Betty’s support she has

come to recognize the risk to her child, if not to herself. She has

established a medical home for the child and seeks care appropriately.

She has begun to take action to change her living situation in order

to improve her health and that of her child. In this case, the barrier

to health literacy promotion is not the mother’s reading skill, it is

the grandmother’s beliefs.

Promoting Health Literacy

Betty planned to keep bringing information on smoking to each visit

with this family, as she has for a year now, and continue to do

whatever she can to “get them to stop smoking”. When we reviewed

the mother’s goals and motivations - she aims to complete her

schooling so she can get a job so she can move to a more healthful

environment - a different approach emerged that is likely to be

more effective and less frustrating for all parties.

Betty has been trying to fix the family and rescue Baby by

getting Mom and Grandma to stop smoking. If she could shift

from pushing for her own goal to supporting what Mom wants

for herself and the baby, she could build on Mom’s motivation

to graduate and get a job, celebrate smoking outside and going

to school as steps in the right direction, and support Mom’s

step-by-step progress toward independent living and a smoke-free

environment for her and Baby.

Epilogue

At the end of the case presentation, we learned the baby

had just been taken to the local ER with seizures and

airlifted to the regional medical center. We cannot say that

second- and third-hand smoke caused the seizures, but the

evidence is clear that smoke in an infant’s environment

weakens lung function and increases other health risks.

Mom is right. Time to move.

References

Winickoff JP, Friebely J, Tanski SE, et al. (2009). Beliefs

about the health effects of “third hand smoke and

home smoking bans. Pediatrics 123: e740e79.

Chan S.& Lam TH. (2003). Preventing exposure to second-hand smoke.

Seminars in Oncology Nursing 19 (4): 284-290

MedlinePlus Secondhand Smoke in Childhood Linked to Lung

Disease Years Later

http://www.nlm.nih.gove/medlineplus/news/fullstory_1231000.html

(available until 6/17/2012)

Socking a Child is Not Discipline; It is an ACE

03/09/2012 10:49:00

I was on the street corner waiting for the light to change as they approached.

She was fashionably dressed, a one-year-old on her hip and shopping bags on

her arm. The five-year-old boy walked along beside her. He struggled with a

backpack that seemed too big for him. She stopped; turned to him and shouted

“Get that backpack on before I sock the shit out of you!”

The boy jumped in surprise and alarm. So did I. She seemed so angry so

suddenly.

The boy had been quiet and well-behaved, keeping pace with his mother.

The problem seemed obvious. He was wearing a puffy parka a size too large;

it bunched up at the shoulders when he tried to pull up the straps.

I was speechless.

What would you do?

My instinct was to protest. And I was afraid she would sock the shit out of me,

too. The light changed and I went on.

I have been disappointed in my non-response and worried about the child since.

If she socked me, I could have socked her back. The boy could not. If the police

came, he may have gained some protection.

Contemplating the scene, I thought maybe I could have interceded without blaming

or embarrassing her by saying something like, “Gee, your hands are full, can I help

him with the backpack?”

What would you do?

This boy was having an ACE (Adverse Childhood Experience)

Thinking about the mother, I suspect ACEs in her background make violence her

automatic reaction and prevent her from feeling compassion and raising a

compassionate child. It is likely she speaks to her child the way her parents

spoke to her and/or perhaps as someone currently speaks to her.

In any case, neither threatening the boy nor actually socking him will teach him

to carry his backpack properly, or to obey his mother. It will teach him to fear

his mother and do whatever keeps him from getting hit. It will teach him that

socking the shit out of someone is how you solve problems, and that it is OK

if you are the biggest and strongest. It will convince him that he is bad and

unworthy of respect.

Using Beginnings Parents Guide to talk about discipline vs. hitting

If I were her home visitor or parent educator or outreach specialist, I would

plan a reflective conversation with this mother. I might start with page 186

of the Beginnings Parents Guide, titled “What do you want to teach?”

Take a look.

Beginnings Parents Guide Update: Discipline by Time Out

03/07/2012 20:56:00

The dad was carrying his two-year-old son to the park. The boy fussed

and squirmed as Dad talked in his ear. Suddenly, Dad plunked the boy

down on the sidewalk and took three steps away from him. “OK, that’s

a three-minute time out!” he said louder than he intended. The fussing

escalated to a cry. Dad sighed heavily, hands on hips, and glowered at

the boy and the passersby.

First, kudos to this dad. He recognized that he and the boy both needed

a break. He did not let his frustration get the better of him. He did not

hit or threaten. But he could have used time-out more effectively.

Discipline is Teaching Self Control, Not Punishing “Bad” Behavior

Like his dad, when a toddler is upset, he has trouble thinking.The

point of time out is not to punish him, but to help him regain his

calm and self-control; and to create an an opportunity for Dad to

regain his calm and self-control, too.

Wrong Place for Time Out

A noisy, busy sidewalk with adults and pets bustling between them

and traffic whizzing by is not a soothing environment. If Dad could

have made it another half block they would have been in the park

where they could sit on a bench or on the beach to be quiet together,

give words to feelings, and regroup. Sitting together would show the

boy that his dad did not reject him, only his behavior. It would also

show that everyone (even Dad) gets upset and needs a break sometimes

to regain composure. Naming the boy’s feelings would prepare him to

use words instead of fussing.

Unreasonable Expectations

The two-year-old is too young for time out. At his stage of cognitive

development, it is unlikely that time-out makes any sense to him.

So now in addition to whatever made him cranky, he feels frightened,

rejected and confused to find himself dumped alone on the sidewalk

with his angry dad backing away from him. A two-year old understands

that No! means Stop. But he has no idea what to do instead. He does

not understand that what he wants and feels is not the same as what

his dad wants and feels. He has no clue what three minutes means.

He has an innate fear of being abandoned, a survival mechanism

designed to keep him safely close to his parents; so seeing Dad walk

away is not going to calm him.

Time out is a good form of discipline starting around age three. And

then three minutes is about right, one minute per year of age.

Not the Desired Result

Dad wanted to teach self control, but ended up teaching fear. He

wanted his son to be good, but showed him he is bad. He wanted

to feel good about himself and his son, but both were feeling pretty

bad when I saw them.

For More on Effective Time Out, see Beginnings Parents Guide, Book 8,

pages 183 to187. For discipline for a toddler aged 24-30 months,

see Book 7, pages 162-164. This information requires no revisions

for the upcoming 4th Edition.

Next: While this dad did not use time out as well as he could have,

he is way ahead of a mother I encountered a little later.

Eat Well: Key Message with a Lifelong Health Impact

03/05/2012 11:10:00

“Eat well” is a Key Message in both the Beginnings Pregnancy Guide

and the Parents Guide. Nutrition is a topic warranting consistent,

frequent discussion and planning with mothers in prenatal care and

postpartum visits, home visiting, parent education, medical home

outreach, and well-child and well-woman visits. We are reviewing

the nutrition information in the Parents Guide to prepare the

forthcoming 4th edition. Here’s why nutrition matters even more

than we thought:

Chronic disease starts in the womb

For every 10 Americans who die each year; seven succumb to a

chronic disease. Heart disease, cancer, and stroke account for half

of all deaths. Risks for- and protections against such diseases,

plus type 2 diabetes, obesity, hypertension and osteoporosis,

begin to accumulate before birth. Nutrition plays a major role.

Adult health problems can be set in motion during pregnancy and

early childhood through “early programming”. That term refers

to exposures during sensitive development periods that may

permanently alter the function of organs and body systems. For

example, if during pregnancy a mother gets too few calories, or

sufficient calories but few essential nutrients, the baby’s body

adjusts development to make use of whatever is available. These

adjustments help ensure survival of the infant, but create organs

and systems that do not fit a healthier environment, placing the

child at risk, even in the presence of nutritious foods. Children

who did not thrive in the womb, and then consume excess calories

are at greatest risk for adult health problems.

Risks (low quality food, lack of exercise, excess weight) accumulate

over time. On the other hand, protections (breastfeeding, prenatal

vitamins, high quality foods in appropriate portions) also accumulate.

Critical periods when exposure to risks and protections either promote

or compromise development and future health include pregnancy,

and birth to age 3, the timeframes addressed in the Beginnings Guides..

“Nutrition Literacy” is not enough

Enabling mothers and families to eat well, takes more than health

education to ensure understanding what makes a healthy diet. It

takes supports that enable mothers to act on their knowledge. It

takes supports for breastfeeding initiation and continuation after
return to work. It takes transportation to stores that carry quality

food at affordable prices. It takes time to plan and prepare meals.

It takes safe places to exercise. And it takes “food security”.

For most of us reading this, nutritious safe food is plentiful and
easy to get. That contributes to our physical and mental health

and school performance. But many of the families we serve enjoy

no such food security; 37% of households headed by a single woman

and 43% of families living below the federal poverty line live with

low quality food or hunger.

Want to know more, do something?

This information comes from a free online course from the

University of Washington Northwest Center for Public Health

Practice. The course is addressed to practitioners and includes
tools for addressing maternal child nutrition in your community.

It is self-paced and takes about an hour and 15 minutes to complete.

Check it out.

Babies are co-sleeping with their parents

02/28/2012 16:40:00

I conducted an informal Facebook poll to test directly the proposition that

some parents are going to choose co-sleeping, despite the widely publicized

recommendations of experts that infants sleep alone to prevent SIDS. Some

of these parents may be unaware of the risk, or may not understand the

message. I surmised that parents engaging in parenting-related Facebook

discussions are likely to be aware of the message and to understand it.

I asked: When you child was an infant (up to 8 months old), did you bring

the baby to your bed?

Often Never Routinely Occasionally

The single question poll was posted on Facebook for the month of February.

Almost immediately, an anonymous reader added a response option, “every night”,

which received by far the most votes. Here’s the tally.

37 every night

3 never

3 routinely

1 if he woke up we brought him in

1 occasionally

Talk about safe bed-sharing

Non-scientific as it is, the result makes it clear; we need to talk about how to

make co-sleeping as safe as possible. Simple advice that Baby must always sleep

alone in his/her own crib is not going to fly. But this is the proper advice when

parents habitually use alcohol or drugs, or are taking prescription medications

that suppress arousal.

“Baby Back to Sleep” still the most important message

Parents have enough anxiety. It is important to emphasize the risk period for

SIDS peaks at 2-4 months. SIDs is rare before age 1 month and after age 6

months. A safe solution during the early months seems to be temporary bed-sharing,

where the baby shares the parents’ bed for feeding and cuddling and then is

returned to a crib within sight. Use of a pacifier at sleep time (not other times)

reduces risk of SIDS. So does a firm mattress, tightly fitted bedding and removal

of all things fluffy and soft. In all cases and places, Baby sleeps face-up.

Here’s a summary of references and resource from our review of evidence on SIDS:

Beginnings Parents Guide Update: Parent–Infant Bed Sharing

New Findings on Co-Sleeping and SIDS

SIDS/Protective Factors

Safe Crib Safe Sleep

Promoting Maternal Health Literacy: Helping parents use crib safety info

Pacifiers protect against SIDS, but what about breastfeeding?